Left atrial intramural hematoma – a rare complication following radiofrequency ablation of atrial fibrillation: a case report

Abstract Background Ablation is increasingly used to treat atrial fibrillation (AF), and recognising potential complications is essential. We present a case of left atrial intramural hematoma after radiofrequency ablation (RFA), successfully managed with a conservative approach. Case summary A 39-year-old man underwent pulmonary vein isolation (PVI). During RFA with a contact-force catheter, the areas close to the left superior pulmonary vein, including the left atrial appendage, roof, and posterior wall, showed absent electrical signal. Left atrial scarring was suspected. PVI was completed. On the following day, the patient had chest pain. Transthoracic echocardiography revealed pericardial effusion and a large left atrial mass. Computed tomography confirmed a left atrial intramural hematoma extending into the left atrial cavity. Anticoagulation was discontinued. The patient developed worsening chest tightness on postoperative day two due to increasing of pericardial effusion. Pericardiocentesis was performed to relieve symptoms, and 400 ml of bloody fluid was drained. The effusion did not progress further. The drain was removed three days later, and the hematoma was managed conservatively with a favorable outcome. Discussion Left atrial intramural hematoma can occur following left atrial RFA. Diagnosis relies on multimodality imaging, including echocardiogram and computed tomography. Furthermore, intra-procedural mapping abnormalities, such as a large low-voltage area, may indicate an evolving complication. Early recognition of this rare but potentially life-threatening complication can guide prompt and appropriate management. In stable patients, close clinical and imaging follow-up is appropriate, as shown in our case. In severe cases with hemodynamic compromise, urgent surgical intervention may be required.